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HBS Update - February 14, 2016

Walt Curlee - I Love Farm Life T Shirt - Appalachian Blackberry Patch 2 - Rural Farm Landscape

Happy Valentine's Day

Another Holiday has come and gone as you read this. Valentine's Day is a day to express and share your love for the ones you hold dear, so we hope you have had a wonderful day with the one's you love. Valentine's day requires gifts so let's start off by providing a few for you. First, we have established a Facebook group called the Rural Health Clinics Information Exchange. This group is a place for you to exchange information related to RHCs. On a typical day, I spend about 4 hours answers questions about RHCs from clients or just about anyone who calls and I post the links to the information on this site. Many are very helpful and of course any recent news regarding RHCs will be posted in the group as well. You are welcome to post questions on the site as well as cost report season is upon us and my question answering time will be extremely limited very soon. Here is the link to the website.

"A place to share and find information on RHCs."

Showing a little more love for the RHC community we have started up our free webinars again and are putting together a series of seminars for this summer as well. 

Here are the links to the Webinars:

Please register for:
HCPCS Coding Changes effective April 1, 2016. 
A Brief Overview. 
Feb 18, 2016 2:00 PM EST  


This webinar will focus on the recent revised guidance that CMS provided RHCs for billing effective April 1st, 2016. 
There are some issues that will take some time to code correctly and may cause billing issues in the future. 
Also procedures are going to be handled differently as well as the use of modifier 59.

After registering, you will receive a confirmation email containing information about joining the webinar.

Brought to you by GoToWebinar®
Webinars Made Easy®

RHC Cost Reporting for 2016 for Office Managers, Administrators, and RHC Providers. on Feb 25, 2016 2:00 PM EST at: 

RHC Billing and Regulatory changes for 2016 including HCPCS changes effective April 1, 2016 on Mar 17, 2016 2:00 PM EDT at: 

Chronic Care Management Billing for RHCs on Apr 13, 2016 2:00 AM EDT at: 

FAQ on Chronic Care Management Released in February, 2016

Additionally, we have started a YouTube Channel and it has all the recordings of previous webinars on it

Recorded Webinars on RHC Billing, Cost Reporting, Certification, and Annual Evaluations 

RHC Cost Report Information 
We have been hard at work mailing cost report agreements, HIPAA Business Associate agreements, Medicare Checklists, and P S and R instructions to our clients. It is a long process as thankfully there are a lot of you. Look for the following documents in the mail very soon. If you do not get one and want us to prepare your cost report, please let us know and we will get them out to you. Everyone should have this by the end of next week if all goes as planned. These are the documents that will be extremely helpful as you pull the information together to send to us to prepare the cost reports. Here are the links to the documents you will need.


Changes to Chapter 13 of the RHC Manual have been released

CMS has published the new Chapter 13 manual for RHCs. The changes are noted in red in the manual and they are as prescribed in MLN 9442 issued in January, 2016.

Medlearn Matters 9442

Revised Chapter 13 RHC Manual

Advance Care Planning (ACP) Services furnished by Rural Health Clinics (RHCs)


On April 14th my only child (Ashley Rose) is turning 16. The only thing she wants for her birthday is to go to Italy. In her long, long life it seems like a crime that she has not been. (teenagers!!!) Anyway, even though I have no time she has me wrapped around her little finger so for her school's spring break we are going to Italy from March 24th to April 3rd. Josh and another accounting intern will continue to work on cost reports while I am away and with technology I can review files in Dropbox relatively easy - but please hold the phone calls and texts if possible during this time period unless it is an emergency. We will have some international roaming minutes, but they tend to run out fast and there is a 7 hour time difference so please be aware of that.  If you need me during this period, it is best to email me at (please do not use or copy the email to Thank you for understanding and helping out in this request. 

If you can get your cost report information in before that March 24th day, that would be great. I can organize and assign tasks for while I am gone and finish my review when I get back and have your cost report finished. Remember the sooner you get your cost report in the sooner we can get it filed and we will have more time to accurately complete your cost reports and get additional information from you if needed. The cost reports that come in late and at the filing deadline are typically the ones that have issues down the road. 

I have found it is much easier to deal with the issues on the front end than have to deal with them in desk review. For example, if your bad debt log or Medicare flu or pnu shot log is incomplete and the filing deadline is May 31st and we receive your information on May 30th (believe me, it happens), we have to choose to either have your payments cut off by Medicare and wait on the information or file the cost report and ask you to prepare the additional information for the desk review or refiling of the cost report. We also charge a penalty for late submission to us as these late submissions create a massive about of stress to meet filing deadlines.

HCPCS Implementation Transmittal Revised 
On February 10, 2016, CMS reissued the Med-Learn Matters article on HCPCS implementation and clarified  how copayments would work on pages 5 and 6 of the transmittal providing an example.  CMS indicates in this transmittal that the only HCPCS code that will be eligible to generate a co-payment will be the codes from a specific list called the RHC Qualifying Visit List that are considered visits. RHCs will be required to add all charges that are elgible for co-payments and deductibles in the first line of the UB-04. Procedures are still not on that list of visits that are payable. Hopefully, this will be resolved in the future.

The adding all the charges qualifying visit, first line of the UB-04 is going to be a nightmare. First off the UB-04 is not going add up, Your charges presented for those CPT codes are going to completely off (your qualifying visit charges will never be the same if you provide additional services) For example. You have a patient with a 99213 for $100 and you draw blood (36415) and charge $20  and you give an injection and you charge $50 your UB-04 will look like this:

42 Rev Code
47 Total Charges
Deductible Applied
All-inclusive rate (AIR)
Included in AIR
0250 or 0636
Included in AIR
UB will total

This is going to be a programming nightmare, plus it is going to be inaccurate. This system just seems to defeat the whole purpose of doing this. Line 1 is going to be polluted by a conglomeration of things and will make the charge and cost data collected by CMS utterly useless. I think most computer systems will have a difficult time when you try to add other data fields to a current data field to get a total. I am sure it can be done, but not with out a lot of programming and our total charges is still going to inaccurate on the UB-04.

We are going to have two webinars on this subject. One this week on Thursday at 2:00 PM, EASTERN time. (see registration above) Another webinar on March 17th will go deeper into the issues presented by this transmittal and strategies to deal with this reduction in revenues after we have had a chance to talk and hear the speakers at the NARHC meeting.  Here is the revised guidance released on February 10, 2016 for the implementation of HCPCS . Please read it closely and provide any insight you have to us. 

Lets look at the big picture for independent RHCs. Using this table created from the Medicare Cost Reports and complied for the National Association of RHCs by Wifli, we can see that the mean cost per visit for a an independent RHC is $123.64 in 2014. The Medicare cost cap per visit was $79.80 but Medicare does not pay that. Medicare pays 78.4 percent of that (copay and sequestration) so an independent RHC in 2014 received $62.56 per visit no matter what they did or how expensive a medicine they provide the patient. That's it, no more, no less. In a world of $12,000 dollar sleep studies, you see why rural areas are become devoid of healthcare providers. In other words, Independent RHCs receive 50.5% of their cost from Medicare and must generate the other 49.5% from the patient to break even on Medicare. That means the average charge per visit for a Medicare patient must be $305 per patient to break even. Of course, Independent RHCs rarely if ever did that, but could cost justify performing a procedure if the charge was $400 or $500 for the procedure and they would receive 20% of the charge from the patient along with the Medicare payment. Under this new guidance, the RHC would not get paid for the procedure and will have a difficult time programming their computer systems to capture co-payments on incidental or incident to services.  Independent RHCs dependent on Medicare funding for survival will have a more difficult time surviving in this complex world of value-based heath care.

Costs per visit as compared to the Medicare Cap 

Per Visit Cap if Applicable
Mean Cost Per Visit
Provider-based Mean Cost
Per Visit

Our webinar on March 17th will go deeper into the issues presented by this transmittal and strategies to deal with this reduction in revenues.

Visiting Specialists at Provider-based clinics

One item in our last newsletter deserves some clarification. The item on provider-based rural health clinicsnot having visiting specialists due to the exclusive use standard. This rumor started at the National Rural Health Association in Kansas City and I have heard numerous times from attendees at this meeting. It stems from a ruling against a hospital in Helena, Montana. According to my conversations with Bill Finerfrock from the NARHC, this issue does not affect provider-based rural health clinics, only provider based clinics. The speaker at the NRHA meeting was applying the principle to RHCs and it should not have. Here are the links:

Place of Service Codes for Provider-based clinics

More than 4,000 Rural Health Clinics (RHCs) serve the primary care needs of rural communities, and are therefore an important source of primary care and other essential health services for rural residents. Unfortunately, the Rural Health Clinic Program is plagued by a lack of data on the financial, operational, and quality performance of participating clinics. In light of the significant expansion of quality performance reporting and growing use of performance-based payment approaches, it is critically important that RHCs be able to compete in this changing healthcare market. To this end, we piloted the reporting and use of a small set of primary care-relevant quality measures by a geographically diverse sample of RHCs. This policy brief reports on the results of this pilot with a focus on assessing the feasibility and utility of the reporting system and quality measures for the participating RHCs.

Contact Information:
John A. Gale, MS
Maine Rural Health Research Center

Here is the link to the document


RHC Presentations

Here are the presentations from the RHC Conference in Georgia. Here are the handouts and presentations from this excellent conference. If you need to know how to access your P S and R, Julie Quinn's presentation has links to help you. I am still working on getting my cost report letters and notebooks up to date and they should go out as soon as I get back in the office. I have hired a couple of Accounting Interns to help me get my backlog of work out the door. I just can't seem to get off the road here lately.  Again, here are the links and pay special attention to Kathy Whitmire's presentation. They have $31 million dollars to help your practice bill chronic care management and become a Patient Centered Medical Home and the money is not just for Georgia.
Thank You for a Great Rural Health Clinic Conference!
Jan. 27, 2016
A special thank you to our Sponsors and Presenters!
DIRRT - Doing It Right The First Time
Environmental Solutions
inQuiseek, LLC
Business & Healthcare Consulting
Association for Rural Health Professional Coding 
Peach State 

Important Meaningful Use Hardship Waivers Due
I always get in trouble when I mention information like this but here goes, CMS has simplified the meaningful use waiver process. The waiver applications must be submitted by March 15, 2016 for professionals and April 1, 2016 for hospitals and CAHS. Here are the links that will explain the process if this is something you need to accomplish. Remember that in theory RHCs should not face a payment reduction from not achieving meaningful use; however, we thought the same thing about PQRS and there may be unintended consequences of MIPS resulting from the MACRA laws passed in 2015 (see link below)

Meaningful Use Hardship Websites

Merit Based Incentive Based Payment Website

National Association of Rural Health Clinics
Of course there is the National Association of Rural Health Clinics which is the voice of RHCs in Washington, DC. The NARHC offers two institutes each year in the spring and fall which provide invaluable updates and in-depth information for rural health clinic administrators and providers. Here is a list of upcoming events with the next one occurring in San Antonio, Texas on March 14th to the 16th. Here is the link to information on the conference including an agenda and the costs: NARHC Spring Institute - March 14-16, 2016.
If you cannot make the conferences, there is the List Serve that provides timely information and updates as well as an opportunity to ask questions and submit feedback to other RHCs throughout the country. If you are not familiar with what a list serve is it is a mail list which allows its members to communicate through email posts. To post a question on list serve, you must first be signed up on the list serve. To sign up for list serve, click here. The list serve is free to join.
However, remember RHCS need representation on a national level. The numbers bear out that RHCs/FQHCs are the most cost effective way to provide healthcare to vulnerable populations. That story needs to be told and your membership in the NARHC will help tell that story.
Our Partners and what they do



Contact & Phone Number

HPSA Acumen
National Health Service Corp Loan, HPSAs, and MUAs
Joseph Lampard

(716) 483 - 0888

Rural Behavioral
 Health, LLC
Mental Health Services
Dave Jolly
(423) 243-6185
Heart Watch Wellness

& Weight Loss

Dan Haye
(615) 732-0768
AMS Software
RHC Software 
and Services

Matt Kannan
(800) 440-6949

Care 24 / 7
Chronic Care Management
Huy Nguyen, MD
1 (800) 218-3780

 Please use referral code HBS with these partners for special pricing or offers

Healthcare Business Specialists
RHC Cost Reports, Annual Evaluations, Chronic Care Management, Mental Health Services, Preventive Health services including weight loss programs, RHC Seminars and webinars, and Startup consulting for new RHCs. Please call or text Mark R. Lynn, CPA (inactive) at 423.243.6185 or email Please visit our website at for more information.

T hank you for reviewing this information and your confidence in us to assist you with your cost report preparation, annual evaluations, RHC startups, and RHC education. We look forward to seeing you at one of the conferences, seminars, or webinars in the near future.


Mark R. Lynn, CPA (Inactive)
Healthcare Business Specialists, LLC
Suite 214, 502 Shadow Parkway
Chattanooga, Tennessee 37421
Telephone: (423) 243-6185